Inadequate management for secondary fracture prevention in patients with distal radius fracture by trauma surgeons

Association between a history of major osteoporotic fractures and subsequent hip fracture: a systematic review and meta-analysis

PURPOSE

A history of fractures involving the distal radius, proximal humerus, spine, and hip may be associated with the incidence of subsequent hip fractures in older people. However, a comprehensive summary of this association using a rigorous methodology is lacking. Our objective was to systematically review the literature and examine the association between four major osteoporotic fractures and subsequent hip fractures in individuals aged ≥ 50 years.

METHODS

We searched MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov on February 15, 2023. The search included cohort or case-control studies investigating the association between these four types of osteoporotic fractures and subsequent hip fractures. We pooled the hazard ratios (HRs) with 95% confidence intervals (CI) using the random-effects model. We used the Quality In Prognosis Studies tool to assess the risk of bias in the included studies, and the grading of recommendations assessment, development, and evaluation approach to determine the certainty of evidence.

RESULTS

The selection process identified 48 studies for qualitative synthesis and 23 studies (2,239,217 participants) for meta-analysis. The overall methodological quality had a low risk of bias in 65% of the included studies. The association between a history of major osteoporotic fractures and subsequent hip fracture varied, with a high certainty of evidence for a history of proximal humerus and hip fractures (HR 2.02, 95% CI 1.75-2.33 and 2.86, 95% CI 1.92-4.25, respectively), moderate certainty for distal radius fractures (HR 1.66, 95% CI 1.53-1.81), and low certainty for spine fractures (HR 1.53, 95% CI 1.38-1.69).

CONCLUSIONS

In conclusion, a history of major osteoporotic fractures, particularly distal radius, proximal humerus, and hip fractures, is associated with subsequent hip fractures in older adults. Further research is needed to verify the association between a history of spine fracture and subsequent hip fractures.

PROTOCOL REGISTRATION

Open Science Framework ( https://osf.io/7fjuc ).

Computed Tomography of the Chest as a Screening Tool for Low Bone Mineral Density

INTRODUCTION

Computed tomography (CT) Hounsfield units (HU) recently emerged as a promising screening tool for low bone mineral density (BMD). We hypothesized that CT HU measurements of the thoracic spine would significantly and positively correlate with dual X-ray absorptiometry (DXA) BMD scans of the femoral neck.

MATERIALS AND METHODS

The study included patients with DXA scans and thoracic CT scans at the Walter Reed National Military Medical Center. One author, blinded to the DXA scans, measured HU from the cancellous bone in T4 vertebrae. Another author statistically compared femoral neck DXA T-scores to the CT HU measurements.

RESULTS

The study included 145 patients with CT scans and femoral neck DXAs. The osteoporotic and osteopenic groups had a significant difference in HU measurements compared to the normal group within the study (P < .0001 and .002, respectively). A low BMD screening value of 231 HU provided a sensitivity of 90.1% and negative predictive value of 85.7%.

CONCLUSION

Thoracic vertebrae HU measurements correlate with a low BMD of the femoral neck as determined by DXA T-scores. A high sensitivity and negative predictive value was achieved with a screening value of 231 HU. Utilization of chest or thoracic spine CT imaging as a screening method provides a quick and available screening tool for assessing low BMD in patients with these scans.Level of Evidence: III (Diagnostic).

Declining Trend in Anti-osteoporotic Treatment, Despite a Rise in DEXA Screening Following "Sentinel" Distal Radius Fractures

PURPOSE

To understand national trends and costs associated with the utilization of anti-osteoporotic medication and DEXA screening within the year following a sentinel/primary distal radius fracture.

METHODS

The 2008-2015Q1 Humana Administrative Claims database was queried to identify patients aged ≥50 years, with a "sentinel" occurrence of a primary closed distal radius fracture. Linear regression models were used to report and assess for significant trends in utilization of anti-osteoporotic medication and DEXA screenings within the year following the fracture. Multivariate logistic regression analyses were used to assess for factors associated with receiving or not receiving anti-osteoporotic medication.

RESULTS

A total of 14 526 sentinel distal radius fractures were included in the study. Only 7.2% (n = 1046) of patients received anti-osteoporosis medication in the year following the distal radius fracture. Treatment with medication for osteoporosis declined from 8.2% in 2008 to 5.9% in 2015, whereas the rate of DEXA screening increased from 14.8% in 2008 to 23.6% in 2015. The most common prescribed treatment was alendronate sodium (n = 835; 79.8%-$49/patient). Factors associated with increased odds of receiving anti-osteoporotic medication were age 70 to 79 years (odds ratio [OR], 1.45; P = .014), age 80 to 89 years (OR, 1.66; P = .001), Asian (OR, 2.95; P = .002) or Hispanic (OR, 1.77; P = .006) ethnicity, belonging to South (OR, 1.19; P = .029) or West (OR, 1.37; P = .010), and having an Elixhauser Comorbidity Index score of 3 (OR, 2.14; P = .024) or > 3 (OR, 2.05; P = .022).

CONCLUSIONS

Despite a rising utilization of DEXA screening following "sentinel" distal radius fractures, the proportion of individuals who receive anti-osteoporotic treatment is decreasing over time.

Risk factors of refracture after a fragility fracture in elderly

The study examined the risk factors of recurrent fragility fractures in elderly. Female and older age increased the risk of refracture. Older age at the first fracture also resulted in shorter time to the second fracture. The prevention program should be emphasized.

PURPOSE

The study examined the characteristics of the fragility fractures and refractures and the factors affecting the incidence and duration to the second fragility fracture.

METHODS

The retrospective cohort study reviewed electronic medical records from Nan Provincial Public Health Office, Thailand. Patients aged ≥ 60 years with fragility fractures (hip, wrist, vertebra, and proximal humerus) from low-energy injuries between 1 January 2009 and 31 December 2018 were included. The characteristics of the first and second fractures and the factors that had effect on refracture incidence and duration were investigated.

RESULTS

Among 4322 patients, 306 patients (7%) had subsequent fragility fractures. Risk factors of refracture included female (adjusted odd ratio 1.79, 95%CI 1.304-2.467) and older age at the first fracture (adjusted odd ratio 1.016, 95%CI 1.003-1.029). Factor resulted in shorter time to second fracture was older age at the first fracture (β-coefficient - 0.96, 95%CI - 1.4-(- 0.5)). Any type of the first fracture resulted in similar risk and duration to subsequent fracture. Half (48%) and two-third (65%) of the second fractures occurred within 3 and 4 years, respectively.

CONCLUSION

Female and older age were risk factors of subsequent fragility fracture. Older age resulted in shorter time to the second fracture. Refracture prevention program should be initiated in patients with any type of first fragility fracture and should be continued for at least 3-4 years.

Patients undergoing surgical treatment for low-energy distal radius fractures are more likely to receive a referral and participate in a fracture liaison service program

INTRODUCTION

Patients often do not receive osteoporosis screening after a low-energy distal radius fracture (DRF). The effect of osteoporosis on the healing of DRFs remains a debate, and it is unclear if surgical treatment of this injury affects the referral and participation rates in a fracture liaison service (FLS) program. The purpose of this study is to report on a large cohort of low-energy DRFs and identify demographic, clinical, and treatment factors that affect referral and participation rates in an FLS program.

METHODS

A retrospective review identified patients over 50 years old who sustained a low-energy DRF between 2013 and 2018. Patients with high-energy or unknown injury mechanisms were excluded. The primary outcome was the effect of DRF surgical treatment on referral and participation rates in an FLS program. Secondary outcomes included patient demographic and clinical characteristic effects on referral and participation rates in an FLS program.

RESULTS

In total, 950 patients met inclusion criteria. Two hundred thirty patients (24.2%) were referred and 149 (15.7%) participated in the FLS program. Patients who underwent surgery were more likely to be referred to the FLS (OR 1.893, CI 1.403-2.555, p < 0.001) and participate in the FLS program (OR 2.47, CI 1.723-3.542, p < 0.001) compared to patients who received non-operative treatment of their DRF.

CONCLUSIONS

Patients who undergo surgical treatment of a low-energy DRF are more likely to be referred and participate in a FLS program. Further study is needed to identify why surgical treatment may affect referral and participation rates.

Relationship between distal radius fracture severity and 25-hydroxyvitamin-D level among perimenopausal and postmenopausal women

Aims

Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency.

Methods

This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared.

Results

The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities.

Conclusion

Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D₃ supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study.

Cite this article: Bone Jt Open 2022;3(3):261–267.

Distal radius fracture: An opportunity for osteoporosis intervention

Background

Distal radius fractures have been reported as a predictor of subsequent osteoporotic fragility fractures. This retrospective study evaluated the proportion of patients with distal radius fractures at a government hospital in Hong Kong who received diagnostic evaluation or treatment for osteoporosis within 1 year.

Methods

Five hundred sixty-one postmenopausal women aged >50 years admitted to a public hospital between 2013 and 2017 for a low-energy distal radius fracture were analysed for initiation of osteoporosis medications and/or arrangement of dual-energy X-ray absorptiometry screening within 1 year of injury.

Results

Within 1 year, 8.4% of patients were prescribed osteoporosis medication and 6.1% of patients had dual-energy X-ray absorptiometry arranged. Patients with a previous fracture were more likely to receive osteoporosis medication (18.6% vs 7.5%, P = 0.012) and either intervention (screening or medication) overall (23.3% vs 10.4%, P = 0.011).

Conclusions

Few postmenopausal women who suffered a distal radius fracture received osteoporosis intervention within 1 year. Orthopaedic surgeons should be aware of the possibility of underlying osteoporosis and opportunity for intervention when managing fragility distal radius fractures.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.

PURPOSE

Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.

METHODS

We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.

RESULTS

Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.

CONCLUSION

The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Bone health assessment via digital wrist tomosynthesis in the mammography setting

Bone fractures attributable to osteoporosis are a significant problem. Though preventative treatment options are available for individuals who are at risk of a fracture, a substantial number of these individuals are not identified due to lack of adherence to bone screening recommendations. The issue is further complicated as standard diagnosis of osteoporosis is based on bone mineral density (BMD) derived from dual energy x-ray absorptiometry (DXA), which, while helpful in identifying many at risk, is limited in fully predicting risk of fracture. It is reasonable to expect that bone screening would become more prevalent and efficacious if offered in coordination with digital breast tomosynthesis (DBT) exams, provided that osteoporosis can be assessed using a DBT modality. Therefore, the objective of the current study was to explore the feasibility of using digital tomosynthesis imaging in a mammography setting. To this end, we measured density, cortical thickness and microstructural properties of the wrist bone, correlated these to reference measurements from microcomputed tomography and DXA, demonstrated the application in vivo in a small group of participants, and determined the repeatability of the measurements. We found that measurements from digital wrist tomosynthesis (DWT) imaging with a DBT scanner were highly repeatable ex vivo (error = 0.05%-9.62%) and in vivo (error = 0.06%-10.2%). In ex vivo trials, DWT derived BMDs were strongly correlated with reference measurements (R = 0.841-0.980), as were cortical thickness measured at lateral and medial cortices (R = 0.991 and R = 0.959, respectively) and the majority of microstructural measures (R = 0.736-0.991). The measurements were quick and tolerated by human patients with no discomfort, and appeared to be different between young and old participants in a preliminary comparison. In conclusion, DWT is feasible in a mammography setting, and informative on bone mass, cortical thickness, and microstructural qualities that are known to deteriorate in osteoporosis. To our knowledge, this study represents the first application of DBT for imaging bone. Future clinical studies are needed to further establish the efficacy for diagnosing osteoporosis and predicting risk of fragility fracture using DWT.

Coding and prescription rates of osteoporosis are low among distal radius fracture patients in Japan

INTRODUCTION

This study aimed to clarify the coding and prescription rates for osteoporosis in distal radius fracture patients and to investigate the associated factors to help prevent subsequent osteoporotic fracture.

MATERIALS AND METHODS

Between 2014-2015, among 294,374 eligible individuals (42% female) aged 50-75 years in a health insurance claims database, we identified 192 individuals (mean age: 59.8 years, 74% female), counted the coding of distal radius fracture (International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) code: S525, S526), and determined if the patient had been assigned the code for osteoporosis and been prescribed osteoporosis medications. Logistic regression was performed to identify factors related to each rate.

RESULTS

The osteoporosis coding rate and osteoporosis medication prescription rate were 17.2% (n = 33) and 10.9% (n = 21), respectively. Most codes were assigned ≤ 3 months after injury (88%) at the distal radius fracture treatment facilities (84.8%). Patients who were assigned the code for osteoporosis or treated with osteoporosis medications were older (p = 0.08, p = 0.02, respectively), female (p = 0.05, p = 0.06, respectively) and having comorbidity (p = 0.02, p = 0.07, respectively). After adjustment, being female and having comorbidity remained the independent factors for the assignment of the code for osteoporosis (OR: 3.30, 95%, CI: 1.08-10.07, OR: 2.77, 95% CI: 1.24-6.12, respectively). No factor remained significant for the osteoporosis prescription. Active vitamin D analogues were most frequently prescribed medication (67%) followed by bisphosphonates (48%).

CONCLUSION

The overall coding and prescription rates for osteoporosis after distal radius fracture were low, which suggested that physician adherence to the osteoporosis guideline was low.

Secondary prevention of fragility fractures in Asia Pacific: an educational initiative

The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.

Cervical Spine Computed Tomography Hounsfield Units Accurately Predict Low Bone Mineral Density of the Femoral Neck

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

The objective of this study to determine the correlation between Hounsfield unit (HU) measurements from the C4 vertebral body and dual-energy x-ray absorptiometry (DXA) T-score.

SUMMARY OF BACKGROUND DATA

Recent attention has turned to the utilization of HU measurements from computed tomography (CT) as a potential screening method for low bone mineral density (BMD). We hypothesized that cervical spine CT HU measurements will correlate with BMD measurements conducted with DXA scans of the femoral neck.

MATERIAL AND METHODS

Patients with cervical CT and femoral neck DXA scans at 1 institution were included in the study. HUs were manually measured from the cancellous bone in the C4 vertebrae by 1 author blinded to DXA scans. HU measurements were compared with femoral neck DXA T-scores for the entire population.

RESULTS

A total of 149 patients with 149 cervical CT and femoral neck DXA scans were included in the study. The low BMD group (osteoporotic and osteopenic combined) showed a significant difference in HU compared with the normal groups within the study (P<0.0001). A low BMD screening value of 447 HU captured over 95% of patients with low BMD within our study and provided a sensitivity of 92% and negative predictive value of 82.1%. The male and female intrasex analysis demonstrated a significant difference between the low BMD and normal BMD groups with P=0.001 and P=0.0001, respectively.

CONCLUSIONS

HU measurements taken from the C4 vertebral body on CT scan correlate with low BMD of the femoral neck as determined by DXA scan T-scores. Screening values of 447 HU captured 95% of patients with low BMD, with a high degree of sensitivity, and negative predictive value of 80%. Utilization of cervical spine HU as a screening method provides a simple, quick, and easily assessable screening tool for assessing low BMD.

LEVEL OF EVIDENCE

Level III-diagnostic.

A national study on long-term osteoporosis therapy and risk of recurrent fractures in patients with hip fracture

OBJECTIVE

The study aimed to evaluate the impact of osteoporosis (OP) medication persistence on subsequent fractures and all-cause mortality in patients with hip fracture.

METHODS

In this retrospective cohort study, we included patients aged ≥ 40 years with fragility hip fracture from the Taiwan's National Health Insurance Research Database. OP medication persistence was categorized as yes (≥ 12 months) or no (< 12 months). A multivariate Cox proportional hazard model was used to evaluate the association between OP medication persistence and recurrent fractures (including hip, vertebral, and upper and lower limb fractures) and all-cause mortality.

RESULTS

A total of 946 patients were included in the study (86.5 % of them aged ≥ 65 years) and 210 patients persistently received OP medications. Persistent OP medication use was associated with lower fracture risk (adjusted hazard ratio [aHR] = 0.64; 95 % CI = 0.41-0.99; P = .043) in the follow-up period. The strongest predictors for all-cause mortality were age ≥ 80 years (HR = 5.68, 95 % CI = 1.36-23.64, P = .017), male sex (HR = 1.55; 95 % CI = 1.18-2.03; P = .002), and Charlson Comorbidity Index ≥ 3 (aHR = 1.56; 95 % CI = 1.07-2.27; P = .022). Kaplan-Meier curves showed a lower cumulative incidence of recurrent fractures in the persistent group than that in the non-persistent group (P = .028).

CONCLUSION

Persistent OP medication use was associated with a lower risk of recurrent fractures but not with mortality in patients with hip fracture.

Osteoporosis liaison service in Japan

A fracture liaison service (FLS) is a secondary fracture prevention program that is led by a coordinator. A program called the osteoporosis liaison service (OLS), which includes FLS, was first implemented in Japan and has become popular for solving problems related to osteoporosis treatment. OLS and FLS have the same purpose, namely preventing fragility fractures, but while FLS focuses mainly on secondary fracture prevention in fracture patients, OLS addresses this issue as well as primary fracture prevention at clinics and in communities.

Clinical decision support system for the management of osteoporosis compared to NOGG guidelines and an osteology specialist: a validation pilot study

Background

Although osteoporosis is an easily diagnosed and treatable condition, many individuals remain untreated. Clinical decision support systems might increase appropriate treatment of osteoporosis. We designed the Osteoporosis Advisor (OPAD), a computerized tool to support physicians managing osteoporosis at the point-of-care. The present study compares the treatment recommendations provided by OPAD, an expert physician and the National Osteoporosis Guideline Group (NOGG).

Methods

We performed a retrospective analysis of 259 patients attending the outpatient osteoporosis clinic at the University Hospital in Iceland. We entered each patient’s data into the OPAD and recorded the OPAD diagnostic comments, 10-year risk of major osteoporotic fracture and treatment options. We compared OPAD recommendations to those given by the osteoporosis specialist, and to those of the NOGG.

Results

Risk estimates made by OPAD were highly correlated with those from FRAX (r = 0.99, 95% CI 0.99, 1.00 without femoral neck BMD; r = 0.98, 95% CI, 0.97, 0.99 with femoral neck BMD. Reassurance was recommended by the expert, NOGG and the OPAD in 68, 63 and 52% of cases, respectively. Likewise, intervention was recommended by the expert, NOGG, and the OPAD in 32, 37 and 48% of cases, respectively. The OPAD demonstrated moderate agreement with the physician (kappa 0.51, 95% CI 0.41, 0.61) and even higher agreement with NOGG (kappa 0.69, 95% CI 0.60, 0.77).

Conclusion

Primary care physicians can use the OPAD to assess and treat patients’ skeletal health. Recommendations given by OPAD are consistent with expert opinion and existing guidelines.

The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures

BACKGROUND

Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention.

METHODS

A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention.

RESULTS

Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model.

CONCLUSIONS

In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.

The Use of Distal Ulnar Hounsfield Units to Predict Future Fragility Fracture Risk

PURPOSE

Distal ulnar Hounsfield unit (HU) measurements obtained from computed tomography (CT) scans of the wrist can be used to accurately screen for low bone mineral density. It is unknown whether HU measurements can also predict the risk of future fragility fractures. Therefore, the purpose of this study was to determine if the HU values of the distal ulna correlate to fragility fracture risk.

METHODS

An electronic database of radiographs at a single institution was searched for all wrist CT scans, obtained for any reason, between January 1, 2002, and December 31, 2008, to allow a minimum of 5-year follow-up. Manual measurement of HU on sequential coronal CT slices of the distal ulnar head was taken, and mean values were recorded. Previously determined cutoff values for the diagnosis of low bone mineral density were implemented to stratify patients as at risk or not at risk for future fragility fracture. Medical records were then manually reviewed for the occurrence of any future fragility fracture (hip, spine, proximal humerus, or rib).

RESULTS

There were 161 CTs in 157 patients and 34 fragility fractures in 21 patients, with a prevalence of 13.4%. The mean HU in the fragility fracture group was significantly lower (134.2 vs 197.1 HU). The percentage of low HU patients with fragility fractures was significantly higher (22.7% vs 3.8%). The odds ratio for fragility fracture in the low HU group was 7.4 (95% confidence interval, 2.1-26.2). Using previously determined cutoff values, the sensitivity and specificity of distal ulna HU values for identifying patients who would sustain at least 1 future fragility fracture were 85.7% and 55.2%, respectively.

CONCLUSIONS

Patients with low distal ulnar HU were significantly more likely to sustain a subsequent fragility fracture. A determination of distal ulnar HUs represents a quick, simple tool to identify patients potentially at risk for fragility fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Opportunistic osteoporosis screening via the measurement of frontal skull Hounsfield units derived from brain computed tomography images

Background and purpose

Osteoporosis is one of the most common chronic metabolic diseases, but detection and treatment rates are low. The aim of the current study was to evaluate the correlation between frontal skull Hounsfield unit (HU) values from brain computed tomography (CT) scans and T-scores of the lumbar spine and femoral neck from dual-energy X-ray absorptiometry (DXA) scans.

Methods

Patients with < 1 year between brain CT and DXA scans were included in the study. The average frontal skull HU value used for analysis was defined as the average of four HU values of the frontal bone. A receiver operating characteristic curve was generated, and area under the curve (AUC) was used to determine the HU values of the frontal skull for predicting osteoporosis. The frontal skull HU value with the highest sensitivity and specificity was considered the optimal cutoff value.

Results

In total, 899 patients who underwent both brain CT and DXA scans at a single institution were enrolled. Average skull HU values differed significantly among patients in different bone mineral density categories (p < 0.001). There was a positive correlation between skull HU value and T-score (β = 105.06, p < 0.001, R² = 0.343). The mean HU value in subjects with osteoporosis was 515, and the optimal cutoff value for the prediction of osteoporosis was 610 HU (AUC = 0.775, 95% CI 0.744–0.806, p < 0.001).

Conclusions

Clinical brain CT scans can assist in the detection of osteoporosis, and patients with an HU value < 610 as determined via brain CT may be considered for further evaluation for possible osteoporosis.

Forearm nonunion caused by hyperparathyroidism with 7 years follow up: A case report

•

We report a patient who developed nonunion of both bones of the forearm associated with hyperparathyroidism.

•

It is necessary to perform close examination to investigate primary disease causing insufficiency fracture.

•

For treatment of nonunion of the 2 forearm bones, osteosynthesis of the ulna alone achieved sufficient osteal support.

Introduction

We report a patient who developed nonunion of both bones of the forearm associated with hyperparathyroidism (HPT).

Presentation of case

The patient was a 71-year-old female who previously fell and hit her left hand on the ground. At 2 years after injury the patient visited our hospital, since she became aware of instability of the left forearm without an inducer due to nonunion of the radioulnar diaphysis. The patient was surgically treated to acquire forearm support. Surgery for nonunion was applied only to the ulna. To acquire an elbow joint flexion angle, an about 30° angle was added to the false joint region. At one year after surgery, blood testing suggested HPT, however, the parathyroid mass was not excised following the current guidelines for management of HPT. At 7 years after surgery, the elbow range of motion, VAS and the Q-DASH score were improved. Weight-bearing by the forearm became possible, and the patient can perform pronation and supination at the radial nonunion.

Discussion

We learned from this case that it is necessary to immediately perform close examination to identify the presence or absence of primary disease causing insufficiency fracture, such as HPT. For treatment of nonunion of the 2 forearm bones in this elderly female, osteosynthesis of the ulna alone achieved sufficient osteal support without osteosynthesis of the radius, and the postoperative course was favorable.

Conclusion

We presented here a rare case of nonunion of both bones of the forearm associated with HPT.

Measurement of Distal Ulnar Hounsfield Units Accurately Predicts Bone Mineral Density of the Forearm

BACKGROUND

Hounsfield unit (HU) measurement obtained from computed tomography (CT) scans of the wrist is a potential new screening method for low bone mineral density (BMD). We hypothesized that HU measurements of the ulnar head obtained from CT scans would correlate with BMD assessed with dual x-ray absorptiometry (DXA) scans of the forearm.

METHODS

Patients with both upper-extremity CT and DXA scans performed at a single institution were included in the study. Hounsfield units were manually measured in the distal part of the ulna by 1 author blinded to the DXA results. Average values were then compared with forearm BMD values as determined with a DXA scan.

RESULTS

Seventy-seven CT scans of 74 patients were included. Average HU values were significantly lower in the osteoporotic and osteopenic groups in comparison with the normal BMD group. The upper limit of the 95% confidence interval for osteopenic patients was 145.9 HU. The average forearm T-score for patients with an HU value at or below the cutoff of 146 was significantly lower than the average T-score for those with an HU value of >146 HU (p < 0.0001). Sensitivity and negative predictive value for low BMD using this cutoff value were calculated to be 91% and 89%, respectively.

CONCLUSIONS

Distal ulnar HU measurements accurately reflect the BMD of the forearm as diagnosed with a DXA scan. Our results suggest that distal ulnar HU measurements of ≤146 HU are strongly associated with low BMD and that values above this cutoff accurately rule out low forearm BMD with a high degree of sensitivity and negative predictive value. Utilizing this technique may improve the capture of at-risk patients and streamline the screening process for osteoporosis.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proceedings of the 2016 Santa Fe Bone Symposium: New Concepts in the Management of Osteoporosis and Metabolic Bone Diseases

The Santa Fe Bone Symposium is an annual meeting of healthcare professionals and clinical researchers that details the clinical relevance of advances in knowledge of skeletal diseases. The 17th Santa Fe Bone Symposium was held in Santa Fe, New Mexico, USA, on August 5-6, 2016. The program included plenary lectures, oral presentations by endocrinology fellows, meet-the-professor sessions, and panel discussions, all aimed to provide ample opportunity for interactive discussions among all participants. Symposium topics included recent developments in the translation of basic bone science to patient care, new clinical practice guidelines for postmenopausal osteoporosis, management of patients with disorders of phosphate metabolism, new and emerging treatments for rare bone diseases, strategies to enhance fracture healing, and an update on Bone Health Extension for Community Healthcare Outcomes, using a teleconferencing platform to elevate the level of knowledge of healthcare professionals in underserved communities to deliver best practice care for skeletal diseases. The highlights and important clinical messages of the 2016 Santa Fe Bone Symposium are provided herein by each of the faculty presenters.

Lack of cooperation between physicians and dentists during osteoporosis treatment may increase fractures and osteonecrosis of the jaw

OBJECTIVE

Our previous questionnaire-based survey suggested that discontinuation of antiresorptive agents before tooth extraction may increase adverse events and disturb osteoporosis treatment without completely preventing osteonecrosis of the jaw (O.N.J.). We also found little cooperation between physicians and dentists in Japan. However, limitations of our previous study included a survey of doctors belonging to small clinics and a small sample size. Our current study aimed to confirm the results of our previous survey in doctors mainly belonging to academia.

METHODS

A structured questionnaire including 14 key clinical queries was sent to 1812 physicians of the Japan Osteoporosis Society, and 629 responses were received.

RESULTS

Dentists requested discontinuation of many medications that were not associated with the incidence of O.N.J. A total of 523 respondents had received discontinuation requests from dentists. Of these, 97 respondents experienced 119 adverse events including 25 fractures and seven incidences of O.N.J. The ratios of valid responses for fractures were 3.6% and 5.3% in patients with a discontinuation of <3 and ≥3 months, respectively. Those for O.N.J. were 0.7% and 1.6%, respectively. Respondents who refused discontinuation requests reported no cases of O.N.J. Approximately 17% of respondents had patients who discontinued osteoporosis treatment following a requested drug discontinuation after tooth extraction. Approximately 62% of respondents did not request oral health care by a dentist before antiresorptive therapy, and 72% reported no cooperation between physicians and dentists in their region.

CONCLUSIONS

This study reconfirms the results of our previous survey. Discontinuation of antiresorptive treatment may increase both fractures and O.N.J. Immediate development of a strategy for sharing information about O.N.J. among physicians, dentists, and patients is required to reduce the incidence of both O.N.J. and skeletal events in osteoporosis treatment. Study limitations were selection bias due to low response rate and possible inaccurate responses to the questionnaire.

Epidemiology of fragility fractures in Sakaiminato, Japan: incidence, secular trends, and prognosis

We investigated the incidence of fragility fractures from 2010 to 2012 in Sakaiminato, Japan. The incidence rates of limb fractures in Sakaiminato were lower than in Caucasian populations but had increased relative to data obtained in Japan in the 1990s. Clinical vertebral fractures occurred at higher rates in Sakaiminato than in Caucasian populations.

INTRODUCTION

To elucidate the incidence and prognosis of fragility fractures in Sakaiminato, Japan.

METHODS

A survey of all hip, distal radius, proximal humerus, and clinical vertebral fractures was performed from 2010 to 2012 in patients aged 50 or older in Sakaiminato city, Tottori prefecture, Japan. The age- and gender-specific incidence rates (per 100,000 person-years) were calculated based on the population of Sakaiminato city each year. The incidence rates of hip, distal radius, and proximal humerus fractures were compared with previous reports. We conducted a follow-up study assessing patients within 1 year following their initial treatment at two Sakaiminato hospitals.

RESULTS

The age-adjusted incidence rates in population aged 50 years or older (per 100,000 person-years) of hip, distal radius, proximal humerus, and clinical vertebral fractures were, respectively, 217, 82, 26, and 412 in males and 567, 432, 96, and 1229 in females. Age-specific incidence rates of hip, distal radius, and proximal humerus fractures all increased since the 1990s. Our study also revealed that anti-osteoporotic pharmacotherapy was prescribed 1 year post-fracture at rates of 29, 20, 30, and 50 % for patients with hip, distal radius, proximal humerus, and clinical vertebral fractures, respectively.

CONCLUSIONS

The incidence rates of limb fractures in Sakaiminato were substantially lower than Caucasian populations in northern Europe but had increased relative to data obtained in Japan in the 1990s. Unlike upper and lower limb fractures, clinical vertebral fractures occurred at higher rates in our study population than in other Asian and North European countries.